2011 Uzbekistan: Formative Evaluation of Improvement of Mother and Child Health Services in Uzbekistan
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Uzbekistan is a landlocked Central Asian country with approximately 30 million people. 37% of the population is estimated to live in urban areas and more than 10% are children below five years of age. In Uzbekistan, steady progress has been made on improving the health, nutrition and wellbeing of mothers and children since gaining the independence in 1991.
The under-five mortality rate fell from 74 to 36 per 1000 live births between 1990 and 2009. However, challenges remain and further improvements are required with a more holistic approach, embracing maternal and child health (MCH), nutrition and wellbeing. The neonatal mortality rate at 26 per 1000 live births is 2.5-3.5 times higher if compared to EU states. 79% of infant deaths occur during the first 30 days of life due to avoidable causes, despite 95% of deliveries are attended by health professionals. The poor quality of maternal, perinatal and early neonatal care is contributing to a high rate of newborn and maternal deaths (maternal mortality is 24 per 100,000 live births).
Over the last decade, several reforms have been implemented to increase the health system’s efficiency, including: reorientation of primary health care, improvement of emergency care and introduction of a basic package of services. Despite such gradual changes, Uzbekistan’s health system retained many features of “Semashko’s model” and the sustainability of the modernization process is not reflected in its governance.
The stewardship function of the Ministry of Health (MoH) is focused on centralized management rather than on policy making and regulation. The reform has been focusing on improving the infrastructure and hardware component and less on improving health care providers’ skills. Thus it did not bring the desired change in the quality of care in its dimensions of safety, effectiveness, patient responsiveness and counseling along the continuum from preconception to adolescent care, particularly care around birth. The concentration of health workers is very high with 134 health providers for every 10,000 people – 5 times more than WHO standards. However, the distribution is uneven, their skills are variable and they are underpaid.
At the same time, the reform has done little to ensure equitable access to and use of services, thus, leaving the room for disparity on morbidity and mortality especially in economically and geographically deprived regions. A recent comparative analysis of MICS 2006 data concludes that under-five and child mortality rates are at least 20% higher in rural areas compared with urban areas and 70% higher among the poorest quintile as compared to the richest.
The Health financing system primarily involves input-based allocation and disregards actual performance and outcomes. According to WHO estimates, the total health expenditure stands at 169 US$ PPP per capita, out of which public health expenditures account for only 42%. Though state-guaranteed contributions are the major source of health sector’s financing, they are mainly utilized on salaries and operational costs. Out of pocket expenditures by families amount for around 60% of the average medical costs, which greatly contributes to raise access barriers and hinder the use of services by the needy part of the population. A recent UNICEF study on child poverty found that 38% of children with common illnesses in poor families are not taken to health facilities because of the unaffordable costs.
In 2003, the Government initiated a sector reform programme to improve maternal and child health services. The Programme, supported by World Bank, ADB, UNICEF, WHO, UNFPA and others, addressed the gaps within the primary health care, supply and in-service training systems.
With technical support from UNICEF, the Ministry of Health (MOH) piloted the innovative Newborn Survival Programme in Ferghana region. The objective was to develop evidence-based training materials on newborn care, neonatal resuscitation, perinatal healthcare surveillance and the International Live Birth Definition and to introduce them through systematic training and supervision. The evaluation showed that the package had an impact on reducing neonatal morbidity and mortality. The latter recommended scaling up the Ferghana model in transitional health systems with established primary care and referral systems. The MOH and UNICEF worked together to plan the expansion and scale-up in other 8 regions. Additional components of child survival, health management and the introduction of maternal child healthcare were included in pre-service training.
As a result of this process and in a partnership between MoH, UNICEF and financial support by the European Commission, the “Improvement of Mother and Child Health Services (IMCHS)” project was designed, aiming at improving health care providers’ skills on quality of care in eight regions of Uzbekistan.
Overall Objective of the project was to support Uzbekistan in meeting the targets of the Millennium Development Goals numbers 4 and 5, with a focus on improving the quality of Mother and Child Health care.
Project’s Specific Objective was to support the implementation of Uzbekistan’s national healthcare reforms through expanding the application of the WHO Live Birth Definition, together with strengthening newborn care and improving the quality of maternal and child health care by developing skills and capacity in pre-natal and newborn care at the hospital level and the management of childhood diseases at the primary health clinics.
The evaluation methodology comprised a mix of site visits and observation, face-to-face semi structured interviews of key informants, focus group discussions, desk-based research and review of existing reports, documents and secondary data.
For key informants interviews the topic guides were developed based on the Evaluation Framework to help ensure systematic coverage of questions and issues. The interview topics have been selected around the evaluation questions, but grouped and targeted according to the organization and/or individual being interviewed.
The Focus Group Discussions (FGDs) were carried out for a) master trainers, b) trained PHC physicians and nurses, trained hospital practitioners, d) trained practitioners on quality control, e) patronage nurses and f) beneficiaries in both regions visited. In total the team carried out 8 FDG in two Project target areas (Namangan and Samarkand). For each FDG the guides were designed. FGD guides for service providers reflected questions relevant to evaluation criteria, while FGD guide for service consumers was oriented towards measuring consumer satisfaction with the services, perceptions of improved quality of MCH service provision and demand for services.
The four major sources of data were used during the evaluation process: people, site visits to a sample of oblasts supported by the IMCHS program, documents and information system.
The design of the evaluation methodology considered ethical issues and applied number of approaches such as i) kept evaluation procedures10 as brief and convenient as possible to minimize disruptions in respondents work process; ii) in order to allow participants to make an informed decision they were information about the purpose of evaluation and final outcome as well as on the process and duration of interview and/or FGD; iii) the respondents were also ensured about the confidentiality of the source for obtained information and allowed them to retain from answering the questions posed in case they felt uncomfortable to respond; iv) key informants were interviewed face to face without presence of other individuals while for the FGD, the grouping (physicians, nurses, beneficiaries etc) has been applied to encourage open discussion around the evaluation questions by avoiding presence of their superiors; and v) collected and analysed information as well as reported findings are accurate and impartial.
The evaluation was a joint and participatory process involving the team of three MOH experts, accompanied the evaluation team during the field visits and semi-structured interviews. For the validation of the preliminary findings and recommendations the team met key MOH staff and Project steering committee members. In General all stakeholders agreed on the main findings of the evaluation as well as noted provided recommendations for further consideration in their respective projects. The evaluation team incorporated stakeholder’s comments for final formulation of the evaluation findings and recommendations. Specifically, relevant stakeholders were given the opportunity to comment on the draft evaluation report and the final evaluation report reflects these comments and acknowledged any substantive disagreements.
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